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BACKGROUND: The population health inpatient Medicare Advantage pharmacist (PHIMAP) intervention is a pharmacist-led, transitions-of-care intervention that aims to reduce hospital readmissions among Medicare Advantage beneficiaries. PHIMAP includes inpatient pharmacist participation in interdisciplinary rounds, admission and discharge medication reconciliation, pharmacy staff delivery of discharge medications to the bedside, personalized discharge medication lists and counseling, and communication with outpatient pharmacists through an electronic health record. OBJECTIVE: To evaluate the effect of the PHIMAP intervention on unplanned 30-day same-hospital readmissions among Medicare Advantage patients. METHODS: Those included were patients admitted to a large urban academic medical center between May 2018 and March 2020 who had a Medicare Advantage plan and were aged at least 18 years. A 2-group, quasi-experimental design was utilized. Control patients received the usual care, which included a best possible medication history and a postdischarge phone call. A multivariable logistic regression model was estimated to predict unplanned 30-day same-hospital readmissions. This study was a Hypothesis Evaluating Treatment Effectiveness study. RESULTS: In total, 884 patients were included. The majority were White (59.0%), non-Hispanic (87.7%), English speaking (90.5%), and older adults (median age, 75 years; interquartile range, 70-83 years). We detected no statistically significant association between the PHIMAP intervention and unplanned 30-day same-hospital readmissions (odds ratio [OR] = 0.91, 95% CI = 0.56-1.52). After adjusting for patient demographics and clinical covariates, significant predictors of 30-day readmissions included the number of emergency department/inpatient visits within 180 days prior to index admission (OR = 1.40, 95% CI = 1.11-1.77); discharge to a post-acute care facility, such as an inpatient rehabilitation facility, long-term acute care facility, or skilled nursing facility (OR = 1.69, 95% CI = 1.06-2.66); hospital length of stay in days (OR = 1.04, 95% CI=1.01-1.07); and the Agency for Healthcare Research and Quality Elixhauser Comorbidity Index score (OR = 1.01, 95% CI = 1.01-1.02). CONCLUSIONS: Significant predictors of readmissions among Medicare Advantage beneficiaries were consistent with greater illness severity, including a recent history of prior hospital utilization, a discharge to post-acute care facility (vs home), a longer length of hospital stay, and a higher comorbidity burden. Although we detected no statistically significant association between PHIMAP and unplanned 30-day same-hospital readmissions, differences in study group assignment based on the day of hospital discharge (weekend vs weekday) was a noted limitation of this study. Future studies of inpatient pharmacist-led interventions should plan to minimize the risk of selection bias due to differences in the time of patient discharge. DISCLOSURES: This study was supported in part by the National Institute on Aging under award number R01AG058911 (to Pevnick) and the UCLA Clinical Translational Science Institute (UL1 TR001881). The sponsor had no role in the design and conduct of the study, nor the writing of this report.

OBJECTIVE: To evaluate outcomes associated with an integrated inpatient and outpatient program aimed at optimizing the care of geriatric fracture patients in a mixed community and academic health system setting. DATA SOURCES AND STUDY SETTING: This study took place at a tertiary-care, 886-bed hospital system. The Geriatric Fracture Program (GFP) was designed in 2018 using the 4Ms Framework (What Matters, Medication, Mentation, and Mobility). Patients ≥65 years old with non-spine fractures managed by orthopedic faculty surgeons and participating hospitalist groups were included. A fracture liaison team educated patients regarding bone health and ensured ambulatory geriatrics follow-up. Outpatient geriatric visits focused on mobility, fall risk, bone health imaging, and medications. STUDY DESIGN: We compared GFP-enrolled patients (n = 746) to patients seen by non-GFP-participating physicians (n = 852) and used a generalized estimating equations approach and Poisson models to analyze associations between participation in the GFP program and four inpatient outcomes (time to surgery, length of stay, Vizient length of stay index, and total direct costs). We examined outcomes across all fractures and also stratified them by fracture type (hip vs. non-hip). We descriptively examined post-discharge care outcomes: fall, gait, and balance assessments; bone health imaging; and medications. DATA COLLECTION/EXTRACTION METHODS: We collected data through chart reviews/electronic health record extracts from July 2018 to June 2021. PRINCIPAL FINDINGS: GFP-enrolled patients with all fracture types had a significantly lower length of stay (marginal effect [ME]: -2.12, 95%CI: -2.61, -1.63), length of stay index (ME: -0.33, 95%CI: -0.42, -0.25), and total direct costs (ME: -$5316, 95%CI: -$6806, -$3826); the magnitude of the effects was greater for non-hip fractures. There was no significant difference in time to surgery. Of 746 GFP patients, 170 (23%) had a post-discharge visit with a participating geriatrician ≥6 months. CONCLUSIONS: A systematic approach to improving care for older adults with fractures improved length of stay and total direct costs.

ObjectiveSocial isolation and loneliness are associated with morbidity and mortality in older adults. Limited evidence exists regarding which interventions improve connectedness in this population.Design/setting/participantsIn this pre-post study we assessed community-based group health class participants' (age ≥50) loneliness and social isolation. Participants (n = 382) were referred by a Cedars-Sinai Medical Network (Los Angeles, California) healthcare provider or self-referred from the community (July 2017-March 2020).InterventionParticipants met with a program coordinator and selected Arthritis Exercise, Tai Chi for Arthritis, EnhanceFitness, or the Healthier Living Workshop.MeasurementsWe measured social isolation using the Duke Social Support Index (DSSI) and loneliness using the UCLA 3-item Loneliness Scale at baseline, class completion, and 6 months.ResultsMean age was 76.8 years (standard deviation, SD = 9.1); 315 (83.1%) were female; 173 (45.9%) were Non-Hispanic white; 143 (37.9%) were Non-Hispanic Black; 173 (46.1%) lived alone; mean baseline DSSI score was 26.9 (SD = 4.0) and mean baseline UCLA score was 4.8 (SD = 1.8). On multivariable analysis adjusted for gender, race/ethnicity, income, self-rated health, and household size, DSSI improved by 2.4% at 6-week compared to baseline (estimated ratio, ER: 1.024; 95% confidence interval [CI]: 1.010-1.038; p-value = 0.001), and 3.3% at 6-month (ER: 1.033; 95% CI: 1.016-1.050; p-value

BackgroundOlder adults commonly face challenges in understanding, obtaining, administering, and monitoring medication regimens after hospitalization. These difficulties can lead to avoidable morbidity, mortality, and hospital readmissions. Pharmacist-led peri-discharge interventions can reduce adverse drug events, but few large randomized trials have examined their effectiveness in reducing readmissions. Demonstrating reductions in 30-day readmissions can make a financial case for implementing pharmacist-led programs across hospitals.Methods/designThe PHARMacist Discharge Care, or the PHARM-DC intervention, includes medication reconciliation at admission and discharge, medication review, increased communication with caregivers, providers, and retail pharmacies, and patient education and counseling during and after discharge. The intervention is being implemented in two large hospitals: Cedars-Sinai Medical Center and the Brigham and Women's Hospital. To evaluate the intervention, we are using a pragmatic, randomized clinical trial design with randomization at the patient level. The primary outcome is utilization within 30 days of hospital discharge, including unforeseen emergency department visits, observation stays, and readmissions. Randomizing 9776 patients will achieve 80% power to detect an absolute reduction of 2.5% from an estimated baseline rate of 27.5%. Qualitative analysis will use interviews with key stakeholders to study barriers to and facilitators of implementing PHARM-DC. A cost-effectiveness analysis using a time-and-motion study to estimate time spent on the intervention will highlight the potential cost savings per readmission.DiscussionIf this trial demonstrates a business case for the PHARM-DC intervention, with few barriers to implementation, hospitals may be much more likely to adopt pharmacist-led peri-discharge medication management programs.Trial registrationClinicalTrials.gov Identifier: NCT04071951.

Altered mental status (AMS) and coma are terms used to describe disorders of arousal and content of consciousness. AMS may account for up to 4% to 10% of chief complaints in the emergency department setting and is a common accompanying symptom for other presentations. AMS is not a diagnosis, but rather a term for symptoms of acute or chronic disordered mentation, including confusion, disorientation, lethargy, drowsiness, somnolence, unresponsiveness, agitation, altered behavior, inattention, hallucinations, delusions, and psychosis. Some of the most common disorders associated with AMS are underlying medical conditions, substance use, and mental disorders. This document focuses on the appropriateness of neuroimaging in adult patients presenting with AMS changes including new onset delirium or new onset psychosis. In these cases, imaging is often expedited for initial stabilization and to exclude an intracranial process requiring intervention. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

Breast cancer incidence increases with age, but many older women do not receive appropriate mammography screening. A tool to support provider decision making holds potential to help providers and patients reach the best-informed decisions possible. We developed and tested a decision aid (DA) for healthcare providers to use in mammography screening recommendations in older women. Literature review, expert opinion, focus groups, and pilot testing of the DA were conducted in a university ambulatory geriatrics practice. Provider evaluations of the DA after piloting were collected and analyzed. Geriatricians reported important factors in decision making included patient life-expectancy, preferences, cognitive function, and individualization. Geriatricians reported the DA would have helped them make recommendations for mammography screening in 66% of pilot cases. It was less helpful when there was more certainty regarding decision making.

Introduction: Older adults face several challenges when transitioning from acute hospitals to community-based care. The PHARMacist Discharge Care (PHARM-DC) intervention is a pharmacist-led Transitions of Care (TOC) program intended to reduce 30-day hospital readmissions and emergency department visits at two large hospitals. This study used the Consolidated Framework for Implementation Research (CFIR) framework to evaluate pharmacist perceptions of the PHARM-DC intervention.Methods: Intervention pharmacists and pharmacy administrators were purposively recruited by study team members located within each participating institution. Study team members located within each institution coordinated with two study authors unaffiliated with the institutions implementing the intervention to conduct interviews and focus groups remotely via telecommunication software. Interviews were recorded and transcribed, with transcriptions imported into NVivo for qualitative analysis. Qualitative analysis was performed using an iterative process to identify "a priori" constructs based on CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation) and to create overarching themes as identified during coding.Results: In total, ten semi-structured interviews and one focus group were completed across both hospitals. At Site A, six interviews were conducted with intervention pharmacists and pharmacists in administrative roles. Also at Site A, one focus group comprised of five intervention pharmacists was conducted. At Site B, interviews were conducted with four intervention pharmacists and pharmacists in administrative roles. Three overarching themes were identified: PHARM-DC and Institutional Context, Importance of PHARM-DC Adaptability, and Recommendations for PHARM-DC Improvement and Sustainability. Increasing pharmacist support for technical tasks and navigating pharmacist-patient language barriers were important to intervention implementation and delivery. Identifying cost-savings and quantifying outcomes as a result of the intervention were particularly important when considering how to sustain and expand the PHARM-DC intervention.Conclusion: The PHARM-DC intervention can successfully be implemented at two institutions with considerable variations in TOC initiatives, resources, and staffing. Future implementation of PHARM-DC interventions should consider the themes identified, including an examination of institution-specific contextual factors such as the roles that pharmacy technicians may play in TOC interventions, the importance of intervention adaptability to account for patient needs and institutional resources, and pharmacist recommendations for intervention improvement and sustainability.Trial Registration: NCT04071951 . [ABSTRACT FROM AUTHOR]